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Entertainment-Education for Better Health |
 
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| February 2008 Issue No. 17 |
The INFO Project • Johns Hopkins Bloomberg School of Public Health • Center for Communication Programs • 111 Market Place, Suite 310 • Baltimore, Maryland 21202, USA • 410-659-6300 • 410-659-6266 (fax) • www.infoforhealth.org • infoproject@jhuccp.org | |
From Drama to Games: A Range of E-E Formats
Selecting program formats is one of the important steps in the design of an entertainment-education (E-E) project. The choice depends mainly on the audience and on the objectives and budget of the communication program. Programs often use several formats in a multimedia campaign. Program managers can choose from a variety of formats.
Dramas in the mass media. Dramas can be presented as series or serials. In the broadcast media dramas are an effective and cost-effective way to reach large audiences (see Investing in Mass Media: Getting the Most for the Money and Web Table 1).
A serial drama, or soap opera, is a continuing story, usually presented on radio or TV once a week for 6 to 12 months or more. A shorter version, the miniseries, generally comprises four to six episodes (58, 80).
The serial drama has several advantages. The continuing story allows for the creation of a lifelike social context and characters who change slowly and face successes and setbacks as in real life. Audiences have time to get to know the characters and identify with them. With a main plot and several subplots, the serial drama can explore issues in-depth and from the perspective of several characters (73, 92). Each subplot can present a story for a specific audience.
In contrast to the serial, the drama series presents a new and complete story in each episode. Many of the same main characters appear in every episode, however. Having a new story for each episode suits audience members who could not watch or listen to every episode in a drama serial (93). In the drama series what attracts and holds the audience are the characters, their different personalities, and how they interact in various situations. As audience members get to know and empathize with the characters, they enjoy anticipating how each character will respond to a new situation or a new lesson.
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The continuing story allows for the creation of a lifelike social context and characters who change slowly and face successes and setbacks as in real life. |
For example, since 1997 the NGO Minga Peru has produced Bienvenida Salud (Welcome Health), a variety show that includes a drama series. Local radio stations in the Peruvian Amazon broadcast the 30-minute show three times a week. The main characters of the drama are a young woman and her mother-in-law, who often get into arguments. Episodes deal with family planning, sexually transmitted infections, maternal health, early marriage, education for girls, and domestic violence. At least 25,000 people listen to the show each week (34, 62, 93, 112).
Because each episode can deal with a different topic, the drama series has been used for distance education of health care providers. For example, various episodes of a distance education drama series started in 2001 for community health workers in Zambia have covered HIV prevention and transmission, immunization, clean water, and community mobilization. A continuing mystery in the personal life of the main character, Sister Evelina, provided suspense to keep the audience coming back for the next episode (17, 44).
Public service announcements (PSAs) or advertising spots are a common and versatile form of E-E. Generally a few minutes or less in length, they can inform audiences, show a benefit of behavior change, correct misinformation, or expose a social ill (2, 19). For example, the international nongovernmental organization Breakthrough produces TV and radio spots for a campaign in India called “Is this justice?” The campaign is designed to bring social change by exposing the cruelty of stigmatizing women whose husbands gave them HIV. In one 60-second spot a man parking his car bumps into some parked motorcycles and then slaps his wife. The voice-over points out that blaming women because they have HIV is like blaming a woman for her husband’s poor driving (16).
The situation comedy, or sit-com, relies heavily on the foolish or exaggerated behavior of several leading characters to engage the audience. Like the drama series, the sit-com is a set of separate episodes that can each highlight a new health topic. It is difficult to present serious subjects in a comic environment, however. Therefore, comedy must be used with great care in E-E. For example, in The 9th Circle, a Jordanian sit-com set in a restaurant, the comic characters are restaurant employees who are not involved in delivering information about family planning. Instead, the customers of the restaurant—for example, young adults, newlyweds, and older people—explain and promote the health benefits of family planning.
Feature films in Bangladesh, India, Mexico, Turkey, and other countries have explored themes of family planning or gender equality. Films can be shown on TV and in cinemas and recorded on videotape (19). For example, in Turkey the 90-minute film Berdel, produced by the Family Health and Planning Foundation, was shown on TV three times in 1992. It portrayed the consequences of son preference and unequal treatment of daughters as part of a multimedia campaign to promote family planning. Sixty percent of people surveyed in 14 provinces said that they had seen Berdel. Turkey’s two most popular film stars played the main characters, and the film won several international film awards (121, 122).
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Popular music and music videos by well-known performers can attract young people’s attention to messages of sexual responsibility and make the messages appealing. Among the first E-E songs and music videos were “Cuando Estemos Juntos” (When We Are Together) and “Detente” (Wait) by Tatiana and Johnny, two of the most popular singers in Mexico in the 1980s. The songs encouraged young people to wait before having sex, getting married, or becoming pregnant. Both songs were hits in Mexico and other Latin American countries (52). A similar project in the Philippines in the late 1980s featured the popular singer Lea Salonga and the group Menudo (83).
Some organizations reach young people in school with dances and songs about reproductive health and HIV. Examples are the Ashe Caribbean Performing Arts Ensemble and Dance4Life, which works in schools mainly in Africa and Europe (1, 32). Young people also perform their own songs. For example, in Rio de Janeiro in 1999–2000, young peer educators in the Guy-to-Guy Project wrote a rap song, “United for Peace” and sang it after performing their play, Cool your head, man. The song and play encouraged young men to stop being violent with each other and with young women (9).
Reality programming, also called “actuality” programming, presents everyday people, rather than actors, telling their own true stories. They speak in testimonials, interviews, diaries, or talk shows primarily on the radio. (Reality programming for E-E differs from “reality programming” on American and British television, where everyday people are put into artificial situations.) For example, a 2004–2005 project in Malawi trained people with AIDS to produce radio diaries each week about an important event or issue in their lives. The diarists talked about relationships with partners, family, friends, and their communities; about medical issues and the attitudes of health care providers; and about emotional stress (42).
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In areas without access to mass media, mobile film units have brought variety shows about family planning, child survival, and HIV prevention to thousands of people. |
Magazine or variety programs comprise a number of segments or formats, which the hosts weave together into a single presentation for broadcast or on stage. The format is designed to appeal to a wide range of listeners or viewers. The “magazine” format allows the educational content to be repeated in several segments of a single program. For example, a radio variety show from 2000 to 2003 in Ghana, part of the Linkages Project, promoted breastfeeding with songs, dramas, comedies, call-in segments, quizzes, and discussions with nutrition experts. The project also included training of health care providers and community members, and community activities (81).
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In areas without access to mass media, mobile film units have brought variety shows about family planning, child survival, and HIV prevention to thousands of people. In Bangladesh, for example, such units show informational films, dramas, testimonials by local leaders, and product advertising. They also show feature films, music videos, and news and sports clips for pure entertainment (79). In India the Community Media Initiative used a video van to show episodes of Jasoos Vijay, a TV detective drama with a theme of HIV prevention. Thanks to the video van, people in 1,200 towns in Uttar Pradesh saw the episodes and participated in discussions and interactive games that accompanied the shows (105).
Theater and street theater are performed live, usually in a central community location. Theater can quickly and powerfully draw people’s attention to an important health topic such as family planning, female genital cutting, violence against women, or HIV prevention (3, 9, 24, 38, 45, 64, 117). People without access to radio or TV can watch. For example, in Bolivia, Teatro Trono enlists street children to perform plays for street children about drugs, self esteem, leadership, and gender equity (38). A street theater production can be performed in many locations. For example, in Lima, Peru, a play to correct misinformation about contraceptives, Ms. Rumors, was performed about 200 times from 1991 to 1994 in parks and squares and for people waiting at hospitals and clinics. In all, about 61,000 people saw the play (117). As a play is repeated in different places, it can be adapted to address local concerns (61, 65). Folk media, performed by community members, often combine theater and music (98).
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Puppets can depict sensitive or controversial situations because they are an illusion rather than seeming to be real people. |
Forum theater or interactive theater is a version of street theater. Like radio or TV dramas, street theater leads to discussion among audience members. Forum theater encourages and facilitates this. The cast invites the audience to participate in the drama, exploring the problems raised and the possible solutions (65). Forum theater is a type of “Theater of the Oppressed,” Augusto Boal’s concept of using theater to motivate social change (13). For example, Nalamdana, a street theater troupe in Tamil Nadu, India, performs dramas about HIV/AIDS, maternal and child health, children’s rights, suicide prevention, cancer, and women’s empowerment. The troupe typically performs in a village square or an urban slum. As many as 1,000 people attend, and the performance is interactive. After the performances, actors—who are trained in HIV counseling— discuss the educational content with audience members (38, 91).
Puppetry is a special form of street theater and has addressed themes of maternal and child health, family planning, and HIV prevention (3, 25). Puppets can depict sensitive or controversial situations because they are an illusion rather than seeming to be real people. The audience can understand their message without being offended (53).
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Animated cartoons, comic books or graphic novels, and photonovelas can be used on their own or to support a broadcast drama or another E-E format (88). For example, animated cartoons in South Asia featuring a smart young girl, Meena, promote equal treatment of girls in education, and access to health services, and protection from early marriage and pregnancy. The carefully researched Meena stories have motivated parents in South Asia to treat their daughters and sons equally (57, 61). Children surveyed in Nepal said that because of Meena boys treat their sisters equally (18). Schools in South Asia use Meena comic books and story books (90). The government literature exam for grade 10 in Bangladesh includes a question about Meena (60).
“Since I saw the film [Meena] I have become very conscious when I serve food to my daughter.” A woman in Dhaka, Bangladesh (61)
Internet and mobile phone programming. The Internet and mobile phones can carry entertaining programming with health messages. For example, in India ZMQ Software Systems develops games for mobile phones to inform young people about HIV and AIDS. One game simulates a football (soccer) match. It provides information about HIV and AIDS when a player scores or prevents a goal (82). The Woodrow Wilson International Center for Scholars in the United States sponsors Games for Health (http://www.gamesforhealth.org/about2.html). This project brings together researchers, game experts, and users to promote games as a way of improving health care. The project also collects best practices and conducts contests for developers of health care games (120).
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Free for Nonprofit Educational Use Family Planning and Reproductive Health |
Entertainment-Education Has Impact
E-E has influenced people’s behavior concerning family planning, reproductive health, and HIV prevention. E-E has helped to motivate contraceptive use and visits to maternal and child health clinics (10, 30, 40, 118). For HIV prevention, E-E projects have motivated people to have fewer sex partners, to be tested for HIV, and to adopt a caring attitude toward people with HIV or AIDS (11, 43, 49, 102).
Analyses of behavior change communication (BCC) projects indicate how E-E projects can influence people. One meta-analysis assessed 39 family planning communication programs in developing countries conducted between 1986 and 2001 (99). Over half of the programs included E-E components such as music, theater, and radio and TV dramas. Among the indicators of impact, the programs had the strongest effect on knowledge of family planning methods. They influenced attitudes, including approval of family planning and intention to use family planning. The programs also influenced behavior such as communication with partners and use of family planning. (For more details on this study, see the companion Population Reports “Communication for Better Health”)
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"We have benefited a lot from the education through your program. Indeed, me and my husband are now actively participating in the use of family planning methods, and we see its advantages." Letter in response to Twende na Wakati, a radio drama in Tanzania (94) |
A systematic review of 24 HIV/AIDS communication programs included 16 projects with E-E components (12). These components included TV and radio dramas, film, a drama broadcast over village loudspeakers, theater, and comic books. The review reported the most consistent effects on knowledge of modes of HIV transmission and decreases in high-risk sexual behaviors, such as reducing the numbers of sexual partners and contacts with commercial sex workers. The review reported mixed results and weak effects on other indicators, such as understanding one’s risk of HIV infection, talking to others about AIDS or condoms, and condom use.
Evaluations find that many different E-E formats have influenced knowledge, attitudes, and behavior related to family planning and reproductive health, including HIV/AIDS.
- TV drama—In South Africa the weekly drama Tsha Tsha addressed HIV prevention, HIV testing, and stigma. In one story line a young woman finds that she has HIV and struggles to tell her friends and family and to adopt a positive attitude. The first 26 episodes in 2003-2004 had an audience of about 1.8 million. An evaluation compared viewers with good recall of the drama and a matched group with low or no recall or exposure. The good-recall group reported significantly more HIV-prevention practices such as abstinence, monogamy, less frequent sex, and condom use (39, 49).
- Radio drama—Since 1993 Twende na Wakati in Tanzania has modeled good and bad behaviors for family planning and HIV prevention. For example, a couple discusses family planning and then chooses a method, and a promiscuous truck driver does not use condoms and becomes infected with HIV. About 40% of new family planning users at government clinics said that they came because of the drama. Twelve percent of listeners adopted a behavior to prevent HIV infection, compared with 1% in a comparison area (11, 86, 94, 118). (For more details on the impact of TV and radio dramas, see Web Table 1)
- TV spots—In 2000 four TV spots broadcast nationally in the Philippines portrayed a couple with two children discussing the benefits of family planning. From national surveys indicating contraceptive use and recall of the spots, researchers estimated that nearly 350,000 women started using a contraceptive as a result of the spots (51).
- Popular music—In Mexico “Cuando Estemos Juntos” and “Detente” were memorable and motivating. When interviewed, young people correctly identified the message of sexual responsibility in the songs. Many had discussed the message with friends and family members (52). In fact, years after the songs were hits, many people still remembered them and the messages (19, 75).
- Variety shows—The radio variety show in Ghana (see Magazine or variety programs) helped to increase significantly the percentage of infants breastfed within one hour of birth from 32% to as high as 62% in project areas. The percentage of infants exclusively breastfed to six months of age increased significantly, as well, from 68% to 79% (81).
- Street theater—An evaluation of performances by Nalamdana in 1996 found significantly increased knowledge about HIV and AIDS and reduced misconceptions among surveyed members of the audience. The performances were especially informative for people with little or no formal education. The performances also changed attitudes of audience members toward people with AIDS. Before the performances 29% said they would shun people with AIDS, 8% said they would turn them over to the police, and 18% said they would treat them the same as other people. After the performances 10% said they would shun, none said they would involve the police, and 50% said they would treat people with AIDS the same as others (116).
- Reality programming—Since 1999 the program Arab Women Speak Out (AWSO) has used video recordings and case histories of successful women as the centerpiece of empowerment workshops in Egypt, Jordan, Lebanon, Palestine, Tunisia, and Yemen. In Egypt, Jordan, and Yemen, participants were significantly more likely than nonparticipants to know where to find health information and to have helped improve community health care. Also, 83% of participants said they make family decisions, compared with 60% of nonparticipants (78).
Like all effective BCC programs, effective E-E projects need to choose formats and communication channels that reach and motivate the audience. Thirteen characteristics of effective BCC programs can be found on page 10 of the companion issue of Population Reports, “Communication for Better Health.”
The Formula for Effective Entertainment-EducationThe formula (5E x Q) + (7C x A) summarizes the important elements of entertainment-education. The 5 Es describe entertainment. Entertainment must: appeal to the emotions, inspire empathy, provide an example of the recommended behavior, persuade the audience that they can carry out the recommended behavior (self-efficacy), and leave them with a sense that the new behavior will enhance their lives. The Q stands for consistently high quality, which will multiply the impact of the 5 Es. The expression 7C x A represents the characteristics of the educational content: correct, complete, consistent, compelling, clear, concise, and culturally appropriate. The A stands for accountability: Project staff must realize that they are accountable for what happens to people if they follow the advice of the E-E program (26). |
(5E x Q) + (7C x A)
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Modern entertainment-education applies a tradition shared by cultures worldwide. People delight in a good story or song that teaches them something—for example, a parable teaching ethical behavior or a folksong challenging injustice. Such entertainment-education has passed important lessons from generation to generation for hundreds or even thousands of years: think ahead, be prepared, treat others as you want to be treated. The media have grown in sophistication and reach, but these lessons are still communicated today through entertainment to improve family planning and reproductive health.
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